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Cicero MX, Baird J, Brown L, Auerbach M, Adelgais K. Frequency, Type, and Degree of Potential Harm of Adverse Safety Events among Pediatric Emergency Medical Services Encounters. PREHOSP EMERG CARE 2023:1-7. [PMID: 37698357 DOI: 10.1080/10903127.2023.2257775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 09/05/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Only 5-10% of emergency medical services (EMS) patients are children, and most pediatric encounters are low-acuity. EMS chart review has been used to identify adverse safety events (ASEs) in high-acuity and high-risk pediatric encounters. The objective of this work was to evaluate the frequency, type, and potential harm of ASEs in varied acuity pediatric EMS encounters. METHODS This cross-sectional study evaluated pediatric (ages 0-18 years) prehospital records from 15 EMS agencies among three states (Colorado, Connecticut, and Rhode Island) between November 2019 and October 2021. Research associates used a previously validated tool to analyze electronic EMS and hospital records. Adverse safety events were recorded in six care categories, grouped into four levels for analysis: assessment/diagnosis/clinical decision-making, procedures, medication administration (including O2), and fluid administration, and defined across five types of ASEs: Unintended injuries or consequences, Near misses, Suboptimal actions, Errors, and Management complications (UNSEMs). Type and frequency of ASEs in each category were rated in three harm severities: Harm Unlikely, Mild/Temporary, or Permanent/Severe. Three physicians verified ASEs determined by research associates. Frequency of ASEs and harm likelihood are reported. RESULTS Records for 508 EMS patients were reviewed, with 63 (12.4%) transported using lights and sirens. At least one clinical intervention beyond assessment/diagnosis/clinical decision-making was documented for 183 (36.1%, 95% CI: 31.8, 40.4) patients. A total of 162 ASEs were identified for 112 patients (22.1%, 95% CI: 18.5, 25.7). Suboptimal actions were the most frequent UNSEM (n = 66, 40.7%; 95% CI: 33.1, 48.3). For ASEs, (n = 162), the most frequent associations were with procedures 39.5% (95% CI: 32.0, 47.0) or assessment/diagnosis/clinical decision making, 32.1%, (95% CI: 24.9, 39.3). Among care categories, fluid administration was associated with significantly more UNSEMs (58.1%, 95% CI:53.8, 62.4). Most ASEs were determined to be 'Harm Unlikely' 62.4% (95% CI: 54.4, 70.4), with assessment/diagnosis/clinical decision making having significantly fewer ASEs with documented harm (22.4%, 95% CI: 10.7, 34.1) compared to other care categories. CONCLUSION Over 20% of pediatric EMS encounters had an identified ASE, and most were unlikely to cause harm. Most frequent ASEs were likely to be associated with procedures and assessment/diagnosis/clinical decision-making.
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Affiliation(s)
- Mark X Cicero
- Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Janette Baird
- Department of Emergency Medicine, Warren Alpert School of Medicine of Brown University, Providence, Rhode Island, USA
| | - Linda Brown
- Department of Emergency Medicine, Warren Alpert School of Medicine of Brown University, Providence, Rhode Island, USA
| | - Marc Auerbach
- Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kathleen Adelgais
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
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Weinstein ES, Bortolin M, Lamine H, Herbert TL, Hubloue I, Pauwels S, Burke RV, Cicero MX, Dugas POT, Oduwole EO, Ragazzoni L, Della Corte F. The Challenge of Mass Casualty Incident Response Simulation Exercise Design and Creation: A Modified Delphi Study. Disaster Med Public Health Prep 2023; 17:e396. [PMID: 37218548 DOI: 10.1017/dmp.2023.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND A Mass Casualty Incident response (MCI) full scale exercise (FSEx) assures MCI first responder (FR) competencies. Simulation and serious gaming platforms (Simulation) have been considered to achieve and maintain FR competencies. The translational science (TS) T0 question was asked: how can FRs achieve similar MCI competencies as a FSEx through the use of MCI simulation exercises? METHODS T1 stage (Scoping Review): PRISMA-ScR was conducted to develop statements for the T2 stage modified Delphi (mD) study. 1320 reference titles and abstracts were reviewed with 215 full articles progressing for full review leading to 97 undergoing data extraction.T2 stage (mD study): Selected experts were presented with 27 statements derived from T1 data with instruction to rank each statement on a 7-point linear numeric scale, where 1 = disagree and 7 = agree. Consensus amongst experts was defined as a standard deviation ≤ 1.0. RESULTS After 3 mD rounds, 19 statements attained consensus and 8 did not attain consensus. CONCLUSIONS MCI simulation exercises can be developed to achieve similar competencies as FSEx by incorporating the 19 statements that attained consensus through the TS stages of a scoping review (T1) and mD study (T2), and continuing to T3 implementation, and then T4 evaluation stages.
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Affiliation(s)
- Eric S Weinstein
- CRIMEDIM, Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department for Sustainable Development and Ecological Transition, Università del Piemonte Orientale, Vercelli, Italy
| | - Michelangelo Bortolin
- CRIMEDIM, Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MassachusettsUSA
| | - Hamdi Lamine
- CRIMEDIM, Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department for Sustainable Development and Ecological Transition, Università del Piemonte Orientale, Vercelli, Italy
- Faculty of Medicine, Ibn Aljazzar of Sousse, University of Sousse, Sousse, Tunisia
| | - Teri Lynn Herbert
- Medical University of South Carolina Library, Charleston, South Carolina, USA
| | - Ives Hubloue
- Research Group on Emergency and Disaster Medicine, Vrije Universiteit Brussel, Brussels, Belgium
| | - Sofie Pauwels
- Research Group on Emergency and Disaster Medicine, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Population and Public Health Sciences and Department of Pediatrics, USC Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Rita V Burke
- Department of Population and Public Health Sciences and Department of Pediatrics, USC Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Mark X Cicero
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Phoebe O Toups Dugas
- Department of Computer Science, New Mexico State University, Las Cruces, New Mexico, USA
| | | | - Luca Ragazzoni
- CRIMEDIM, Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department for Sustainable Development and Ecological Transition, Università del Piemonte Orientale, Vercelli, Italy
| | - Francesco Della Corte
- CRIMEDIM, Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
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Cicero MX, Scherzer DJ. Mass Shooting Drills Are Not the Best Shield for Our Hospitals or Our Children. Simul Healthc 2022; 17:355-356. [PMID: 36260768 DOI: 10.1097/sih.0000000000000696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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Levy AR, Khalil E, Chandramohan M, Whitfill TM, Cicero MX. Efficacy of Computer-Based Simulation as a Modality for Learning Pediatric Disaster Triage for Pediatric Emergency Nurses. Simul Healthc 2022; 17:329-335. [PMID: 34652326 DOI: 10.1097/sih.0000000000000616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
SUMMARY STATEMENT Pediatric disaster triage (PDT) is challenging for healthcare personnel. Mistriage can lead to poor resource utilization. In contrast to live simulation, screen-based simulation is more reproducible and less costly. We hypothesized that the screen-based simulation "60 Seconds to Survival" (60S) to learning PDT will be associated with improved triage accuracy for pediatric emergency nursing personnel.During this prospective observational study, 138 nurse participants at 2 tertiary care emergency departments were required to play 60S at least 5 times over 13 weeks. Efficacy was assessed by measuring the learners' triage accuracy, mistriage, and simulated patient outcomes using JumpStart.Triage accuracy improved from a median of 61.1 [interquartile range (IQR) = 48.5-72.0] to 91.7 (IQR = 60.4-95.8, P < 0.0001), whereas mistriage decreased from 38.9 (IQR = 28.0-51.5) to 8.3 (IQR = 4.2-39.6, P < 0.0001), demonstrating a significant improvement in accuracy and decrease in mistriage. Screen-based simulation 60S is an effective modality for learning PDT by pediatric emergency nurses.
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Affiliation(s)
- Arielle R Levy
- From the Departments of Pediatrics and Emergency Medicine (A.R.L.), Sainte-Justine Hospital University Center, University of Montreal; Department of Pediatrics (E.K., M.C.), McGill University, Montreal, Canada; and Section of Pediatric Emergency Medicine (T.M.W., M.X.C.), Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
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Nelson AR, Cone DC, Aydin A, Burns K, Cicero MX, Couturier K, Rollins M, Shapiro M, Joseph D. An Evaluation of Prehospital Adenosine Use. PREHOSP EMERG CARE 2022; 27:343-349. [PMID: 35639665 DOI: 10.1080/10903127.2022.2084579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Adenosine has been safely used by paramedics for the treatment of stable supraventricular tachycardia since the mid-1990s. However, there continues to be variability in paramedics' ability to identify appropriate indications for adenosine administration. As the first of a planned series of studies aimed at improving the accuracy of SVT diagnosis and successful administration of adenosine by paramedics, this study details the current usage patterns of adenosine by paramedics. METHODS This cross-sectional retrospective study investigated adenosine use within a large northeast EMS region from January 1, 2019, through September 30, 2021. Excluding pediatric and duplicate case reports, we created a dataset containing patient age, sex, and vital signs before, during, and after adenosine administration; intravenous line location; and coded medical history from paramedic narrative documentation, including a history of atrial fibrillation, suspected arrhythmia diagnosis, and effect of adenosine. In cases with available prehospital electrocardiograms (EKGs) for review, two physicians independently coded the arrhythmia diagnosis and outcome of adenosine administration. Statistical analysis included interrater reliability with Cohen's kappa statistic. RESULTS One hundred eighty-three cases were included for final analysis, 84 did not have a documented EKG for review. Categorization of presenting rhythms in these cases occurred by a physician reviewing EMS narrative and documentation. Forty of these 84 cases (48%) were adjudicated as SVT likely, 32 (38%) as SVT unlikely and 12 (14%) as uncategorized due to lack of supporting documentation. Of the 99 cases with EKGs available to review, there was substantial agreement of arrhythmia diagnosis interpretation between physician reviewers (Cohen's kappa 0.77-1.0); 54 cases were adjudicated as SVT by two physician reviewers. Other identified cardiac rhythms included atrial fibrillation (16), sinus tachycardia (11), and ventricular tachycardia (2). Adenosine cardioversion occurred in 47 of the 99 cases with EKGs available for physician review (47.5%). Adenosine cardioversion was also deemed to occur in 87% (47/54) of cases when the EKG rhythm was physician adjudicated SVT. CONCLUSIONS This study supports the use of adenosine as a prehospital treatment for SVT while highlighting the need for continued efforts to improve paramedics' identification and management of tachyarrhythmias.
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Affiliation(s)
- Alexander R Nelson
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - David C Cone
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ani Aydin
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Kevin Burns
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Mark X Cicero
- Department of Pediatrics, Section of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Katherine Couturier
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Mark Rollins
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Matthew Shapiro
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Daniel Joseph
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
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Owusu‐Ansah S, Harris M, Fishe JN, Adelgais K, Panchal A, Lyng JW, McCans K, Alter R, Perry A, Cercone A, Hendry P, Cicero MX. State emergency medical services guidance and protocol changes in response to the COVID‐19 pandemic: A national investigation. J Am Coll Emerg Physicians Open 2022; 3:e12687. [PMID: 35252975 PMCID: PMC8886181 DOI: 10.1002/emp2.12687] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 01/05/2023] Open
Affiliation(s)
- Sylvia Owusu‐Ansah
- Department of Pediatrics Division of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Matthew Harris
- Department of Pediatrics Section of Emergency Medicine Zucker School of Medicine at Hofstra/Northwell Hempstead New York USA
| | - Jennifer N. Fishe
- Department of Emergency Medicine University of Florida College of Medicine – Jacksonville Jacksonville Florida USA
| | - Kathleen Adelgais
- Department of Pediatrics Section of Pediatric Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA
| | - Ashish Panchal
- Department of Emergency Medicine The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - John W. Lyng
- Department of Emergency Medicine University of Minnesota School of Medicine Minneapolis Minnesota USA
| | - Kerry McCans
- Lewis Katz School of Medicine at Temple University Philadelphia Pennsylvania USA
| | - Rachel Alter
- National Association of State EMS Officials Falls Church Virginia USA
| | - Amanda Perry
- Louisiana Department of Health EMS for Children Baton Rouge Louisiana USA
| | - Angelica Cercone
- Department of Pediatrics Division of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Phyllis Hendry
- Department of Emergency Medicine University of Florida College of Medicine – Jacksonville Jacksonville Florida USA
| | - Mark X. Cicero
- Department of Pediatrics Section of Pediatric Emergency Medicine Yale University School of Medicine New Haven Connecticut USA
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Hossain R, Qadri U, Dembowski N, Garcia A, Chen L, Cicero MX, Riera A. Sound and Air: Ultrasonographic Measurements of Pediatric Chest Wall Thickness and Implications for Needle Decompression of Tension Pneumothorax. Pediatr Emerg Care 2021; 37:e1544-e1548. [PMID: 32925707 DOI: 10.1097/pec.0000000000002112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Needle decompression is potentially life-saving in cases of tension pneumothorax. Although Advanced Trauma Life Support recommends an 8-cm needle for decompression for adults, no detailed pediatric guidelines exist, specifically regarding needle length or site of decompression. METHODS Point-of-care ultrasound was used to measure chest wall thickness (CWT), the distance between skin and pleural line, bilaterally at the second intercostal midclavicular line and the fourth intercostal anterior axillary line in children of various ages and sizes. Patients were grouped based on Broselow tape weight categories. Measurements were compared between left versus right sides at the 2 anatomic sites. Interclass correlation coefficients were calculated to assess for interrater reliability. RESULTS A convenience sample of 163 patients from our emergency department was enrolled. For patients who fit into Broselow tape categories, CWT at the second intercostal midclavicular line ranged from 1.11 to 1.91 cm and at the fourth intercostal anterior axillary line ranged from 1.13 to 1.92 cm. In patients larger than the largest Broselow category, 77% had a CWT less than the length of a standard 1.25-in (3.175 cm) catheter. There were no significant differences in the measurements of CWT based on laterality nor anatomic site. CONCLUSIONS The standard 1.25-in (3.175 cm) catheters are sufficient to treat most tension pneumothoraces in pediatric patients.
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Affiliation(s)
| | | | | | - Angelica Garcia
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Lei Chen
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Mark X Cicero
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Antonio Riera
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
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Leff RA, Setzer E, Cicero MX, Auerbach M. Changes in pediatric emergency department visits for mental health during the COVID-19 pandemic: A cross-sectional study. Clin Child Psychol Psychiatry 2021; 26:33-38. [PMID: 33183097 DOI: 10.1177/1359104520972453] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Limited early results indicate that the COVID-19 outbreak has had a significant impact on the mental health of children and adolescents. Pediatric emergency departments (PED) play a pivotal role in the identification, treatment, and coordination of care for children with mental health disorders, however, there is a dearth of literature evaluating the effects of the COVID-19 pandemic on mental health care provision in the PED. OBJECTIVES We sought to evaluate whether changes in frequency or patient demographics among children and adolescents presenting to the PED has occurred. METHODS This is a cross-sectional study conducted at the Yale New Haven Children's Hospital (YNHCH) PED. Data representing the early COVID-19 pandemic period was abstracted from the electronic medical record and compared using descriptive statistics to the same time period the year prior. Patient demographics including patient gender, ED disposition, mode of arrival, race-ethnicity, and insurance status were assessed. RESULTS During the pandemic period, 148 patients presented to the YNHCH PED with mental health-related diagnoses, compared to 378 in the pre-pandemic period, a reduction of 60.84%. Compared to white children, black children were 0.55 less likely to present with a mental health condition as compared to the pre-pandemic study period (p = 0.002; 95% CI 0.36-0.85). CONCLUSIONS Children with mental and behavioral health disorders who seek care in PEDs may be at risk for delayed presentations of mental health disorders. African American children may be a particularly vulnerable population to screen for mental health disorders as reopening procedures are initiated and warrants further study.
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Affiliation(s)
- Rebecca A Leff
- School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer -Sheva, Israel.,Department of Emergency Medicine, Yale University, New Haven, CT, USA
| | - Erika Setzer
- Children's Emergency Department, Yale New Haven Children's Hospital, New Haven, CT, USA
| | - Mark X Cicero
- Department of Emergency Medicine, Yale University, New Haven, CT, USA.,Children's Emergency Department, Yale New Haven Children's Hospital, New Haven, CT, USA.,Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, Yale, New Haven, CT, USA
| | - Marc Auerbach
- Department of Emergency Medicine, Yale University, New Haven, CT, USA.,Children's Emergency Department, Yale New Haven Children's Hospital, New Haven, CT, USA.,Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, Yale, New Haven, CT, USA
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Whitfill T, Auerbach M, Diaz MCG, Walsh B, Scherzer DJ, Gross IT, Cicero MX. Cost-effectiveness of a video game versus live simulation for disaster training. BMJ STEL 2020; 6:268-273. [DOI: 10.1136/bmjstel-2019-000497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/16/2019] [Indexed: 11/04/2022]
Abstract
IntroductionDisaster triage training for emergency medical service (EMS) providers is unstandardised. We hypothesised that disaster triage training with the paediatric disaster triage (PDT) video game ‘60 s to Survival’ would be a cost-effective alternative to live simulation-based PDT training.MethodsWe synthesised data for a cost-effectiveness analysis from two previous studies. The video game data were from the intervention arm of a randomised controlled trial that compared triage accuracy in a live simulation scenario of exposed vs unexposed groups to the video game. The live simulation and feedback data were from a prospective cohort study evaluating live simulation and feedback for improving disaster triage skills. Postintervention scores of triage accuracy were measured for participants via live simulations and compared between both groups. Cost-effectiveness between the live simulation and video game groups was assessed using (1) A net benefit regression model at various willingness-to-pay (WTP) values. (2) A cost-effectiveness acceptability curve (CEAC).ResultsThe total cost for the live simulation and feedback training programme was $81 313.50 and the cost for the video game was $67 822. Incremental net benefit values at various WTP values revealed positive incremental net benefit values, indicating that the video game is more cost-effective compared with live simulation and feedback. Moreover, the CEAC revealed a high probability (>0.6) at various WTP values that the video game is more cost-effective.ConclusionsA video game-based simulation disaster triage training programme was more cost-effective than a live simulation and feedback-based programme. Video game-based training could be a simple, scalable and sustainable solution to training EMS providers.
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Cicero MX, Adelgais K, Hoyle JD, Lyng JW, Harris M, Moore B, Gausche-Hill M. Medication Dosing Safety for Pediatric Patients: Recognizing Gaps, Safety Threats, and Best Practices in the Emergency Medical Services Setting. A Position Statement and Resource Document from NAEMSP. PREHOSP EMERG CARE 2020; 25:294-306. [PMID: 32644857 DOI: 10.1080/10903127.2020.1794085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Millions of patients receive medications in the Emergency Medical Services (EMS) setting annually, and dosing safety is critically important. The need for weight-based dosing in pediatric patients and variability in medication concentrations available in the EMS setting may require EMS providers to perform complex calculations to derive the appropriate dose to deliver. These factors can significantly increase the risk for harm when dose calculations are inaccurate or incorrect. METHODS We conducted a scoping review of the EMS, interfacility transport and emergency medicine literature regarding pediatric medication dosing safety. A priori, the authors identified four research topics: (1) what are the greatest safety threats that result in significant dosing errors that potentially result in harm to patients, (2) what practices or technologies are known to enhance dosing safety, (3) can data from other settings be extrapolated to the EMS environment to inform dosing safety, and (4) what impact could standardization of medication formularies have on enhancing dosing safety. To address these topics, 17 PICO (Patient, Intervention, Comparison, Outcome) questions were developed and a literature search was performed. RESULTS After applying exclusion criteria, 70 articles were reviewed. The methods for the investigation, findings from these articles and how they inform EMS medication dosing safety are summarized here. This review yielded 11 recommendations to improve safety of medication delivery in the EMS setting. CONCLUSION These recommendations are summarized in the National Association of EMS Physicians® position statement: Medication Dosing Safety for Pediatric Patients in Emergency Medical Services.
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Cicero MX, Golloshi K, Gawel M, Parker J, Auerbach M, Violano P. A tabletop school bus rollover: Connecticut-wide drills to build pediatric disaster preparedness and promote a novel hospital disaster readiness checklist. Am J Disaster Med 2019; 14:75-87. [PMID: 31637688 DOI: 10.5055/ajdm.2019.0318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To assess emergency medical services (EMS) and hospital disaster plans and communication and promote an integrated pediatric disaster response in the state of Connecticut, using tabletop exercises to promote education, collaboration, and planning among healthcare entities. DESIGN Using hospital-specific and national guidelines, a disaster preparedness plan consisting of pediatric guidelines and a hospital checklist was created by The Connecticut Coalition for Pediatric Disaster Preparedness. SETTING Five school bus rollover tabletop exercises were conducted, one in each of Connecticut's five EMS regions. Action figures and playsets were used to depict patients, healthcare workers, vehicles, the school, and the hospital. PARTICIPANTS EMS personnel, nurses, physicians and hospital administrators. INTERVENTION Participants had a facilitated debriefing of the EMS and prehospital response to disasters, communication among prehospital organizations, public health officials, hospitals, and schools, and surge capacity, capability, and alternate care sites. A checklist was completed for each exercise and was used with the facilitated debriefing to generate an afteraction report. Additionally, each participant completed a postexercise survey. MAIN OUTCOME MEASURES Each after-action report and postexercise survey was compared to established guidelines to address gaps in hospital specific pediatric readiness. RESULTS Exercises occurred at five hospitals, with inpatient capacity ranging 77-1,592 beds, and between 0 and 221 pediatric beds. There were 27 participants in the tabletop exercises, and 20 complete survey responses for analysis (74 percent). After the exercises, pediatric disaster preparedness aligned with coalition guidelines. However, methods of expanding surge capacity and methods of generating surge capacity and capability varied (p < 0.031). CONCLUSION Statewide tabletop exercises promoted coalition building and revealed gaps between actual and ideal practice. Generation of surge capacity and capability should be addressed in future disaster education.
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Affiliation(s)
- Mark X Cicero
- Associate Professor, Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Klevi Golloshi
- Yale Molecular, Cellular and Developmental Biology, Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Marcie Gawel
- Injury Prevention, Community Outreach, and Research, Yale-New Haven Children's Hospital, New Haven, Connecticut
| | - James Parker
- Associate Professor, Pediatrics and Emergency Medicine/Traumatology, University of Connecticut School of Medicine, Hartford, Connecticut
| | - Marc Auerbach
- Associate Professor, Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Pina Violano
- Manager, Injury Prevention, Community Outreach, and Research, Yale-New Haven Children's Hospital, New Haven, Connecticut
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Sobieraj DM, Martinez BK, Miao B, Cicero MX, Kamin RA, Hernandez AV, Coleman CI, Baker WL. Comparative Effectiveness of Analgesics to Reduce Acute Pain in the Prehospital Setting. PREHOSP EMERG CARE 2019; 24:163-174. [PMID: 31476930 DOI: 10.1080/10903127.2019.1657213] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objectives: The objectives of this study were to assess comparative effectiveness and harms of opioid and nonopioid analgesics for the treatment of moderate to severe acute pain in the prehospital setting. Methods: We searched MEDLINE®, Embase®, and Cochrane Central from the earliest date through May 9, 2019. Two investigators screened abstracts, reviewed full-text files, abstracted data, and assessed study level risk of bias. We performed meta-analyses when appropriate. Conclusions were made with consideration of established clinically important differences and we graded each conclusion's strength of evidence (SOE). Results: We included 52 randomized controlled trials and 13 observational studies. Due to the absence or insufficiency of prehospital evidence we based conclusions for initial analgesia on indirect evidence from the emergency department setting. As initial analgesics, there is no evidence of a clinically important difference in the change of pain scores with opioids vs. ketamine administered primarily intravenously (IV) (low SOE), IV acetaminophen (APAP) (low SOE), or nonsteroidal anti-inflammatory drugs (NSAIDs) administered primarily IV (moderate SOE). The combined use of an opioid and ketamine, administered primarily IV, may reduce pain more than an opioid alone at 15 and 30 minutes (low SOE). Opioids may cause fewer adverse events than ketamine (low SOE) when primarily administered intranasally. Opioids cause less dizziness than ketamine (low SOE) but may increase the risk of respiratory depression compared with ketamine (low SOE), primarily administered IV. Opioids cause more dizziness (moderate SOE) and may cause more adverse events than APAP (low SOE), both administered IV, but there is no evidence of a clinically important difference in hypotension (low SOE). Opioids may cause more adverse events and more drowsiness than NSAIDs (low SOE), both administered primarily IV. Conclusions: As initial analgesia, opioids are no different than ketamine, APAP, and NSAIDs in reducing acute pain in the prehospital setting. Opioids may cause fewer total side effects than ketamine, but more than APAP or NSAIDs. Combining an opioid and ketamine may reduce acute pain more than an opioid alone but comparative harms are uncertain. When initial morphine is inadequate, giving ketamine may provide greater and quicker acute pain relief than giving additional morphine, although comparative harms are uncertain. Due to indirectness, strength of evidence is generally low, and future research in the prehospital setting is needed.
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Cicero MX, Whitfill T, Walsh B, Diaz MCG, Arteaga GM, Scherzer DJ, Goldberg SA, Madhok M, Bowen A, Paesano G, Redlener M, Munjal K, Auerbach M. Correlation Between Paramedic Disaster Triage Accuracy in Screen-Based Simulations and Immersive Simulations. PREHOSP EMERG CARE 2018; 23:83-89. [PMID: 30130424 DOI: 10.1080/10903127.2018.1475530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Disaster triage is an infrequent, high-stakes skill set used by emergency medical services (EMS) personnel. Screen-based simulation (SBS) provides easy access to asynchronous disaster triage education. However, it is unclear if the performance during a SBS correlates with immersive simulation performance. Methods: This was a nested cohort study within a randomized controlled trial (RCT). The RCT compared triage accuracy of paramedics and emergency medical technicians (EMTs) who completed an immersive simulation of a school shooting, interacted with an SBS for 13 weeks, and then completed the immersive simulation again. The participants were divided into two groups: those exposed vs. those not exposed to 60 Seconds to Survival© (60S), a disaster triage SBS. The aim of the study was to measure the correlation between SBS triage accuracy and immersive simulation triage accuracy. Improvements in triage accuracy were compared among participants in the nested study before and after interacting with 60S, and with improvements in triage accuracy in a previous study in which immersive simulations were used as an educational intervention. Results: Thirty-nine participants completed the SBS; 26 (67%) completed at least three game plays and were included in the evaluation of outcomes of interest. The mean number of plays was 8.5 (SD =7.4). Subjects correctly triaged 12.4% more patients in the immersive simulation at study completion (73.1% before, 85.8% after, P = 0.004). There was no correlation between the amount of improvement in overall SBS triage accuracy, instances of overtriage (P = 0.101), instances of undertriage (P = 0.523), and improvement in the second immersive simulation. A comparison of the pooled data from a previous immersive simulation study with the nested cohort data showed similar improvement in triage accuracy (P = 0.079). Conclusions: SBS education was associated with a significant increase in triage accuracy in an immersive simulation, although triage accuracy demonstrated in the SBS did not correlate with the performance in the immersive simulation. This improvement in accuracy was similar to the improvement seen when immersive simulation was used as the educational intervention in a previous study.
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Abstract
OBJECTIVE The aim of this study was to assess the staff perception of a global positioning system (GPS) as a patient tracking tool at an emergency department (ED) receiving patients from a simulated mass casualty event. METHODS During a regional airport disaster drill a plane crash with 46 pediatric patients was simulated. Personnel from airport fire, municipal fire, law enforcement, emergency medical services, and emergency medicine departments were present. Twenty of the 46 patient actors required transport for medical evaluation, and we affixed GPS devices to 12 of these actors. At the hospital, ED staff including attending physicians, fellows and nurses working in the ED during the time of the drill accessed a map through an application that provided real-time geolocation of these devices. The primary outcome was staff reception of the GPS device as assessed via Likert scale survey after the event. The secondary outcomes were free text feedback from staff and event debriefing observations. RESULTS Queried registered nurses, attending physicians, and pediatric emergency medicine fellows perceived the GPS device as an advantage for patient care during a disaster. The GPS device allowed multiple-screen real-time tracking and improved situational awareness in cases with and without EMS radio communication prior to arrival at the hospital. CONCLUSION ED staff reported that the use of GPS trackers in a disaster improved real-time tracking and could potentially improve patient management during a mass casualty event.
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Cicero MX, Whitfill T, Walsh B, Diaz MC, Arteaga G, Scherzer DJ, Goldberg S, Madhok M, Bowen A, Paesano G, Redlener M, Munjal K, Kessler D, Auerbach M. 60 Seconds to Survival: A Multisite Study of a Screen-based Simulation to Improve Prehospital Providers Disaster Triage Skills. AEM Educ Train 2018; 2:100-106. [PMID: 30051076 PMCID: PMC5996818 DOI: 10.1002/aet2.10080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/24/2017] [Accepted: 12/12/2017] [Indexed: 06/01/2023]
Abstract
OBJECTIVES Paramedics and emergency medical technicians (EMTs) perform triage at disaster sites. There is a need for disaster triage training. Live simulation training is costly and difficult to deliver. Screen-based simulations may overcome these training barriers. We hypothesized that a screen-based simulation, 60 Seconds to Survival (60S), would be associated with in-game improvements in triage accuracy. METHODS This was a prospective cohort study of a screen-based simulation intervention, 60S. Participants included emergency medical services (EMS) personnel from 21 EMS agencies across 12 states. Participants performed assessments (e.g., check for pulse) and actions (e.g., reposition the airway) for 12 patients in each scenario and assigned color-coded triage levels (red, yellow, green, or black) to each patient. Participants received on-screen feedback about triage performance immediately after each scenario. A scoring system was designed to encourage accurate and timely triage decisions. Participants who played 60S included practicing EMTs, paramedics, and nurses as well as students studying to assume these roles. Participants played the game at least three times over 13 weeks. RESULTS In total, 2,234 participants began game play and 739 completed the study and were included in the analysis. Overall, the median number of plays of the game was just above the threshold inclusion criteria (three or more plays) with a median of four plays during the study period (interquartile range [IQR] = 3-7). There was a significant difference in triage accuracy from the first play of the game to the last play of the game. Median baseline triage accuracy in the game was 89.7% (IQR = 82.1%-94.9%), which then increased to a median of 100% at the last game play (IQR = 87.5%-100.0%; p < 0.001). There was some variability in median triage accuracy on fourth through 11th game plays, ranging from 95% to 100%, and on the 12th to 16th plays, the median accuracy was sustained at 100%. There was a significant decrease in the rate of undertriage: from 10.3% (IQR = 5.1%-18.0%) to 0 (IQR = 0%-12.5%; p < 0.001). CONCLUSION 60 Seconds to Survival is associated with improved in-game triage accuracy. Further study of the correlation between in-game triage accuracy and improvements in live simulation or real-world triage decisions is warranted.
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Affiliation(s)
- Mark X. Cicero
- Department of PediatricsYale University School of MedicineNew HavenCT
| | - Travis Whitfill
- Department of PediatricsYale University School of MedicineNew HavenCT
| | - Barbara Walsh
- Department of PediatricsDivision of Pediatric Emergency MedicineBoston Medical CenterBoston University School of MedicineNew Hyde ParkNY
| | | | - Grace Arteaga
- Department of Pediatric and Adolescent MedicineMayo ClinicRochesterMN
| | - Daniel J. Scherzer
- Department of Emergency MedicineNationwide Children's HospitalColumbusOH
| | | | - Manu Madhok
- Division of Emergency MedicineChildren's Hospitals and Clinics of MinnesotaMinneapolisMN
| | - Angela Bowen
- Radiation Emergency Assistance Center/Training Site (REAC/TS)Oak RidgeTN
| | | | | | | | - David Kessler
- Department of PediatricsNew York–Presbyterian HospitalNew YorkNY
| | - Marc Auerbach
- Department of PediatricsYale University School of MedicineNew HavenCT
- Department of Emergency MedicineYale University School of MedicineNew HavenCT
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Cicero MX, Whitfill T, Munjal K, Madhok M, Diaz MCG, Scherzer DJ, Walsh BM, Bowen A, Redlener M, Goldberg SA, Symons N, Burkett J, Santos JC, Kessler D, Barnicle RN, Paesano G, Auerbach MA. 60 seconds to survival: A pilot study of a disaster triage video game for prehospital providers. Am J Disaster Med 2017; 12:75-83. [PMID: 29136270 DOI: 10.5055/ajdm.2017.0263] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Disaster triage training for emergency medical service (EMS) providers is not standardized. Simulation training is costly and time-consuming. In contrast, educational video games enable low-cost and more time-efficient standardized training. We hypothesized that players of the video game "60 Seconds to Survival" (60S) would have greater improvements in disaster triage accuracy compared to control subjects who did not play 60S. METHODS Participants recorded their demographics and highest EMS training level and were randomized to play 60S (intervention) or serve as controls. At baseline, all participants completed a live school-shooting simulation in which manikins and standardized patients depicted 10 adult and pediatric victims. The intervention group then played 60S at least three times over the course of 13 weeks (time 2). Players triaged 12 patients in three scenarios (school shooting, house fire, tornado), and received in-game performance feedback. At time 2, the same live simulation was conducted for all participants. Controls had no disaster training during the study. The main outcome was improvement in triage accuracy in live simulations from baseline to time 2. Physicians and EMS providers predetermined expected triage level (RED/YELLOW/GREEN/BLACK) via modified Delphi method. RESULTS There were 26 participants in the intervention group and 21 in the control group. There was no difference in gender, level of training, or years of EMS experience (median 5.5 years intervention, 3.5 years control, p = 0.49) between the groups. At baseline, both groups demonstrated median triage accuracy of 80 percent (IQR 70-90 percent, p = 0.457). At time 2, the intervention group had a significant improvement from baseline (median accuracy = 90 percent [IQR: 80-90 percent], p = 0.005), while the control group did not (median accuracy = 80 percent [IQR:80-95], p = 0.174). However, the mean improvement from baseline was not significant between the two groups (difference = 6.5, p = 0.335). CONCLUSION The intervention demonstrated a significant improvement in accuracy from baseline to time 2 while the control did not. However, there was no significant difference in the improvement between the intervention and control groups. These results may be due to small sample size. Future directions include assessment of the game's effect on triage accuracy with a larger, multisite site cohort and iterative development to improve 60S.
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Affiliation(s)
- Mark X Cicero
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Travis Whitfill
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Kevin Munjal
- Emergency Medicine, Mount Sinai Medical Center, New York, New York
| | - Manu Madhok
- Pediatrics, Children's Minnesota Minneapolis Hospital, Saint Paul, Minnesota
| | | | | | - Barbara M Walsh
- Associate Professor of Pediatrics, Division of Pediatric Emergency Medicine; Director, Pediatric Emergency Medicine Simulation Program, Hofstra School of Medicine, Cohen's Children's Medical Center, New Hyde Park, New York
| | - Angela Bowen
- Radiation Emergency Assistance Center/Training Site (REAC/TS), Oak Ridge, Tennessee
| | - Michael Redlener
- Department of Emergency Medicine, Mount Sinai St. Luke's, New York, New York
| | - Scott A Goldberg
- Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nadine Symons
- Pediatrics, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - James Burkett
- Director, Advanced Physician Assistant Degree Program, Arizona School of Health Sciences, Mesa, Arizona
| | - Joseph C Santos
- Emergency Medical Services for Children, Baylor College of Medicine, Houston, Texas
| | - David Kessler
- Pediatrics, Columbia School of Medicine, New York, New York
| | - Ryan N Barnicle
- Medical School, Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, Connecticut
| | - Geno Paesano
- Sponsor Hospital Program, Yale New Haven Hospital, New Haven, Connecticut
| | - Marc A Auerbach
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
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Burke RV, Lehman-Huskamp K, Whitney RE, Arora G, Park DB, Mar P, Cicero MX. Checklist use in evaluating pediatric disaster training. Am J Disaster Med 2016; 10:285-94. [PMID: 27149309 DOI: 10.5055/ajdm.2015.0210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Disaster preparedness training has a small but growing part in medical education. Various strategies have been used to simulate disaster scenarios to safely provide such training. However, a modality to compare their effectiveness is lacking. The authors propose the use of checklists, which have been a standard in aviation safety for decades. DESIGN Residents at four different academic pediatric residency programs volunteered to participate in tabletop simulation of a timed, pediatric disaster scenario. Resident teams were required to properly triage and manage simulated patients. Care intervention requests corresponding to each of the patients were recorded on a premade checklist. RESULTS Thirty-six teams provided a total of 1,476 possible care intervention requests for three pediatric patients: one with crush injury, one with increased intracranial pressure, and a nonverbal child. Some interventions were more likely to be omitted than others, and some teams performed extra interventions. Twenty-five entries from the checklist intervention responses were missing, affecting three of the teams. On average, teams requested 65 percent, were prompted to request 11 percent, and missed 22 percent of all checklist interventions with only 2 percent of all items not being recorded. Chi-square tests were performed for each patient scenario using R software. Categories compared included total counts of "requested," "prompted," and "missed" responses. Chi-square values were all statistically significant (p value < 0.05). CONCLUSIONS In the checklist use during a tabletop disaster simulation, the authors have demonstrated that the checklist allows trainees to receive near immediate feedback. This training exercise provided them an opportunity to explore their own preparedness for a disaster scenario in a low-stress environment and allows for evaluation of such preparedness in a safe environment.
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Affiliation(s)
- Rita V Burke
- Children's Hospital Los Angeles, Division of Pediatric Surgery, Keck School of Medicine, University of Southern California, California; Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Rachel E Whitney
- Department of Pediatrics, Section of Emergency Medicine, Yale School of Medicine, Connecticut
| | - Gitanjli Arora
- Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Daniel B Park
- Department of Pediatrics, Medical University of South Carolina, South Carolina
| | - Pamela Mar
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mark X Cicero
- Department of Pediatrics, Section of Emergency Medicine, Yale School of Medicine, Connecticut
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Donofrio JJ, Kaji AH, Claudius IA, Chang TP, Santillanes G, Cicero MX, Srinivasan S, Perez-Rogers A, Gausche-Hill M. Development of a Pediatric Mass Casualty Triage Algorithm Validation Tool. PREHOSP EMERG CARE 2016; 20:343-53. [DOI: 10.3109/10903127.2015.1111476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Koziel JR, Meckler G, Brown L, Acker D, Torino M, Walsh B, Cicero MX. Barriers to Pediatric Disaster Triage: A Qualitative Investigation. PREHOSP EMERG CARE 2014; 19:279-86. [DOI: 10.3109/10903127.2014.967428] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
OBJECTIVE Methods currently used to triage patients from mass casualty events have a sparse evidence basis. The objective of this project was to assess gaps of the widely used Simple Triage and Rapid Transport (START) algorithm using a large database when it is used to triage low-acuity patients. Subsequently, we developed and tested evidenced-based improvements to START. METHODS Using the National Trauma Database (NTDB), a large set of trauma victims were assigned START triage levels, which were then compared to recorded patient mortality outcomes using area under the receiver-operator curve (AUC). Subjects assigned to the "Minor/Green" level who nevertheless died prior to hospital discharge were considered mistriaged. Recursive partitioning identified factors associated with of these mistriaged patients. These factors were then used to develop candidate START models of improved triage, whose overall performance was then re-evaluated using data from the NTDB. This process of evaluating performance, identifying errors, and further adjusting candidate models was repeated iteratively. RESULTS The study included 322,162 subjects assigned to "Minor/Green" of which 2,046 died before hospital discharge. Age was the primary predictor of under-triage by START. Candidate models which re-assigned patients from the "Minor/Green" triage level to the "Delayed/Yellow" triage level based on age (either for patients >60 or >75), reduced mortality in the "Minor/Green" group from 0.6% to 0.1% and 0.3%, respectively. These candidate START models also showed net improvement in the AUC for predicting mortality overall and in select subgroups. CONCLUSION In this research model using trauma registry data, most START under-triage errors occurred in elderly patients. Overall START accuracy was improved by placing elderly but otherwise minimally injured-mass casualty victims into a higher risk triage level. Alternatively, such patients would be candidates for closer monitoring at the scene or expedited transport ahead of other, younger "Minor/Green" victims.
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Cicero MX, Brown L, Overly F, Yarzebski J, Meckler G, Fuchs S, Tomassoni A, Aghababian R, Chung S, Garrett A, Fagbuyi D, Adelgais K, Goldman R, Parker J, Auerbach M, Riera A, Cone D, Baum CR. Creation and Delphi-method Refinement of Pediatric Disaster Triage Simulations. PREHOSP EMERG CARE 2014; 18:282-9. [DOI: 10.3109/10903127.2013.856505] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Cross KP, Cicero MX. In reply. Ann Emerg Med 2013; 62:643-4. [DOI: 10.1016/j.annemergmed.2013.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Revised: 06/10/2013] [Accepted: 06/10/2013] [Indexed: 10/26/2022]
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Cross KP, Cicero MX. Head-to-Head Comparison of Disaster Triage Methods in Pediatric, Adult, and Geriatric Patients. Ann Emerg Med 2013; 61:668-676.e7. [DOI: 10.1016/j.annemergmed.2012.12.023] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 12/11/2012] [Accepted: 12/19/2012] [Indexed: 10/27/2022]
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Cicero MX, Northrup V, Li FY, Santucci KA. A recession's impact on pediatric emergency household spending and attitudes about health-care reform. Conn Med 2011; 75:37-42. [PMID: 21329291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND We assessed changes in household spending and opinions about health-care insurance reform among parents in the pediatric emergency department (PED) during the current recession. METHODS We conducted a survey of parents at a PED. Enrollment was in June and July 2009. We assessed demographics, employment and insurance status, and difficulty paying for household expenses. Open-ended questions addressed attitudes about health-care reform. RESULTS Among 467 parents, job loss was associated with difficulty paying for food (OR 2.32, 95% CI 1.53-3.52), housing (3.21, 2.11-4.88), and utilities (2.19, 1.44-3.32). In total, 226 respondents cut household expenses. More respondents cut food expenses (20.8%) and utilities (15.8%) than child health care (12.0%). Of 154 respondents providing opinions about health-care reform, 66.9% endorsed reform, and 9.7% disagreed. CONCLUSION Parents with job loss reported hardship paying for household expenses. One in eight families have cut child health-care expenses. A population of PED parents commonly favored health-care insurance reform.
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Affiliation(s)
- Mark X Cicero
- Yale New-Haven Children's Hospital, Emergency Department, 840 Howard Avenue, New Haven, CT 06504, USA.
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Affiliation(s)
- Mark X Cicero
- Yale University School of Medicine, New Haven, CT, USA
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